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The Use of Assistive
Technology in Rehabilitation
and Beyond
Melissa Oliver, MS OTR/L
Assistive Technology Program Coordinator
McGuire VA Medical Center
Richmond, VA
Objectives
Overview of Assistive Technology (AT)
Role of AT in Physical Medicine and Rehabilitation
AT Evaluation Process
AT in Action (Electronic Cognitive Devices, Adaptive Computer Access, Electronic Aids to Daily Living)
Era of Technology
Assistive Technology
“any item, piece of equipment, or system,
whether acquired commercially, modified
or customized, that is commonly used to
increase, maintain, or improve functional
capabilities of individuals with disabilities”
- The Assistive Technology Act of 2004
AT Evolution
Vocational Rehab Act of 1918
Smith-Fess Act – 1920
Vocational Rehab Act Amendments (1943, 1954 and 1965)
Rehabilitation Act of 1973
Developmental Disabilities Assistance and Bill of Rights Act of 1975
Education of the Handicapped Act of 1975 and Amendments of 1986, 1990 and 2004
Rehabilitation Act Amendments of 1986
Technology Related Assistance Act of 1988, 1994, 1998 and 2004 Amendments
Americans with Disabilities Act of 1990
Rehabilitation Act Amendments of 1992 and 1998
ASSISTIVE TECHNOLOGY…
Communication Aids
◦ Speech and Augmentative Communication Aids
◦ Writing and Typing Aids
Computer Access Aids
◦ Alternative Input Devices
◦ Alternative Output Devices
◦ Accessible Software
◦ Universal Design
Daily Living Aids
◦ Clothing and Dressing Aids
◦ Eating and Cooking Aids
◦ Home Maintenance Aids
◦ Toileting and Bathing Aids
Education and Learning Aids
◦ Cognitive Aids
◦ Early Intervention Aids
Vision and Reading Aids
Environmental Aids
◦ Environmental Controls and Switches
◦ Home-Workplace Adaptations
◦ Ergonomic Equipment
Hearing and Listening Aids
Mobility and Transportation Aids
◦ Ambulation Aids
◦ Scooters and Power Chairs
◦ Wheelchairs
◦ Vehicle Conversions
Prosthetics and Orthotics
Seating and Positioning Aids
Recreation and Leisure Aids
◦ Sports Aids
◦ Toys and Games
◦ Travel Aids
is a generic term that includes assistive, adaptive, and rehabilitative devices for people with disabilities and includes the process used in selecting, locating, and using them.
Rehabilitation’s Role in AT
Role of Rehabilitation and AT
Physicians play a critical role as they will evaluate the patient’s current medical and mental status, identify precautions and areas to evaluate.
Physicians need to be aware that AT is an option and referral sources
Rehabilitation Therapists bring diverse perspectives and specialty for evaluating a patients’ AT needs.
Rehabilitation Team provides Education about AT
Examples of Interdisciplinary approach
◦ Adaptive Sports Clinic
◦ Wheeled Mobility Clinic
◦ Assistive Technology Clinic
AT Clinician's
Role/Responsibilities
Learn the devices &/or software
Become knowledgeable about the Clinical Practice Guidelines -www.prosthetics.va.gov/cprs
Assess the patient’s needs, tasks and environment
Collaborate with patient, family and the team to determine best fit for client
Train the patient and caregiver/staff
Outcome Measures of Satisfaction and Functional Usage
The Right AT Device ?
Team Decision
Consult an Assistive Technology Professional
Short term versus long term need
Low Tech to High Tech
Universal design - Less exclusive
Societal attitudes, Social norms, practices and ideologies
Intrinsic Motivated and Ability Limited
Multi-Context – Beyond the 4 walls of Rehab
BENEFITS & CHALLENGES OF ASSISTIVE TECHNOLOGY
Benefits of AT
Achieve maximum independence
Increase sense of control
Increase participation in life roles
Increases efficiency
Provides a level of privacy and dignity
Decreases caregiver burnout
Supports function in a variety of environments
Portability and appealing
Challenges of AT
Potential for an increase in frustration & anxiety
Ineffective
“One size does not fit all”
Technology overload
Training is more than 1 time
Carryover may not occur
Repairs
AT Evaluation Process
Pulling it all Together
HAAT model (AT Frame of
Reference)• A Model designed specifically for AT
• Consists of Four Components:▫ Human
▫ Activity
▫ Assistive Technology
▫ Context
• Considering each element separately and interactively helps to select, design and implement appropriate AT that fits the individual and his/her lifestyle.
PATIENTat Center of the Team
PCP/SpecialtyProviders
AudiologySLP
Family
Mental HealthPsychology
Vocational Rehab
Manufacturer
Supplier(s)
Funding Sources
Administration PT/OT/KT/RT
Rehab Engineering
TEAM APPROACH
General Overview of
Evaluation for AT• Patient assessment
• Identify patients’ and/or caregivers’ goals
• Identify roles and daily functions effected
• Assessment of patient motivation to use AT devices
• Determine current use and effectiveness of current AT and/or strategies
• Collaboration between patient and health professionals about the type of device that will best suit patient’s needs
• Training in the proper use of the device
AT Clinical Evaluation … Sample
Format of Documentation
Patient Goals
Patient Background
Previous/Existing AT
Devices
Body Systems &
Structures
Activity
Environment
Trials/Simulation
Outcome Measures
Patient Education
Impression/
Recommendations
Plan
Factors for Selection
of AT Devices Patient and Caregiver Goals
Least invasive device available
Physical, mental, and cognitive strengths and challenges
Environment(s) that the device will be used
Patient’s current knowledge & usage of devices
Pros versus Cons of the AT device
Clinical Practice Recommendations
Training time and Follow through
Hierarchy of Assistive Technology
◦ Modify the task
◦ Modify the environment
◦ Commercially available
Products (off the shelf)
No Technology
Low Technology
High Technology
◦ Commercially Available
Products specialized for the
disabled
No Technology
Low Technology
High Technology
◦ Customized Assistive
Technology
Key to Success..
Collaboration with other services and/or disciplines
Co-treat with treating clinicians in several sessions
Training to all staff involved in patient’s care
Comprehensive training and education to caregiver and/or family members of patient
ASSISTIVE TECHNOLOGY IN ACTION
Electronic Cognitive Devices
ECD is a product or
system that is used
by an individual to
compensate for
cognitive
impairments and
support his or her
ability to participate
in ADLS or IADLS
Who Would Benefit from an ECD?
Traumatic Brain Injury
CVA
Multiple Sclerosis
Dementia
PTSD
Schizophrenia
Autism
Others…
Typical Cognitive Problems
Attention
Remembering to do things (medications, appointments)
Memory for names/faces, locales
Task Sequencing
Multi-tasking
Organization
Time Management
Dealing with Distractions
Adapting to transitions and changes in routines
Other Symptoms to Consider
Balance
Visual impairment
Speech impairment
Auditory impairment
Behavioral changes
Initiating and perseverating
[Safety] awareness
What can a ECD Help With?
Assist with Transitions
Participate in Daily Living Activities
Participate in Vocational Tasks
Participate in Community and Recreational Activities
Participate in Educational Opportunities
Scheduling/Reminders
Time Management
Task Sequencing
Behavioral Cues
Directions
What’s in Their Pocket??
EXAMPLES OF ELECTRONIC COGNITIVE
DEVICES
Low-Tech Cognitive Aids
Recorders…Study Aides
Digital Recorder
Dragon Dictation App
Smart Pen
Plain Old Cell Phone
•Carry it everywhere
•Speed Dial for
Frequent Calls
•Text-Messaging
•Contact information
•Camera
•Varied features by
phone
Google Calendar > Cell phone
Text message a
calendar reminder
Can be used on any
cell phone that
allows texting
Personal Digital Assistants
Smartphones
Palm Pre
Apple iphone
Google Android Nexus One
Tablets
Large icons for dexterity-challenged
Louder speaker for augmentative communication
Larger screen
Low Vision
What about APPS???
Apple versus Android
Device Type
Mounting
Accessories
Access
Time Management
Money Management
Medication Management
Activity Analysis for basic and instrumental ADLS
Education
Health Management
Behavioral Management
Communication
Visual & Hearing Impairment
Things to Consider…. APP Categories….
Pillboxie
0.99
IOS
Visual
Alarms
Memory App…iDress for
Weather
$1.99
Any age
Any ability anywhere
in the world!
Memory App…
Keeper Password & Data Vault
• Free
• store and protect
sensitive info such as
credit card numbers,
bank accounts,
passwords, pin
numbers, private notes,
and any other secret
information on your
iPhone or iPAD Touch.
Astrid Tasks/To-do List
Free
Set Tasks
Alarms
Offers Voice
recognition
Add to Calendars
Android and IOS
Super Note: Recorder, Notes,
Memos
$1.99
Records information
Take notes at the same
time
Organize/Categorize
information
Forward the
information
Memory App…Evernote
• Free
• Turns the iPhone, iPod
Touch and iPad into an
extension of your brain,
helping you remember
anything and everything
that happens in your life
• Instantly synchronizes
from your iPhone to your
Mac or Windows desktop
Informant HD Pro App
$14.99
Integrates calendars
and to do tasks
Timelines
Prioritizing
Organization
Case Study…ECD
45 year old male OIF/OEF Veteran
Mild Traumatic brain injury while deployed in Iraq
PTSD
Impaired memory and organization
Hearing Loss
Visual Deficits
Goals:
◦ help with organization for daily activities
◦ remembering appointments
◦ stress management
◦ Get and keep a job
Case Study - ECD, cont.
Device Features needed:
◦ Portable
◦ Light weight
◦ large screen
Case Study-ECD, cont.
Paper calendars/notes
PDA
Cellphone
SmartPhone
iPAD
iPAD
APPS:◦ Stress management
◦ hearing amplification,
◦ spiritual and emotional outlets based on patient’s interests (e.g. bible study)
◦ Organization/time management
Assisted with the following:◦ Organization
◦ Independence
Trailed Results
Research
Mid to late 1990s
Use of PDAs with various diagnosis
Enable Job Support
Enable Community Living
Adaptive Computer Access
Specialized group of hardware and
software designed to enable individuals
with a wide range of disabilities to use a
personal computer
Factors to consider
Patient’s Goals
Computers
◦ Skills
◦ Own a computer??
◦ Windows or
Macintosh based
system
◦ Desktop or Laptop
Environment
Patient’s diagnosis/
prognosis
Patient’s cognition
Other AT Devices
Other Considerations
Seating & Positioning
Lighting
WorkStation
Access
Primary Areas to Address:
Mouse Operations
◦ Pointing
◦ Clicking
◦ Dragging
Text Entry
◦ Numbers
◦ Letters
Mouse Operations
Commercially Available
Products
RollerMouseTrackball
Alternative Mouse Inputs
Mouse Button-BoxFootime Foot Mouse
QuadJoy
Jouse
HeadMouse
TEXT ENTRY
Text Entry
Reduced Size Keyboards Enlarged Keyboards
Low Profile Keyboard
Big Keys
IntelliKeys
Text Entry
Keyboards for Low Vision Software for Low Visions
MaGIC
Other Text Entry Alternatives
Voice Recognition Software On Screen Keyboards
Dragon NaturallySpeaking 11 Premium with Bluetooth Headset
Dragon Dictate forMac
REACH
Other Text Entry
Alternatives Kurzweil
Wynn
Read & Write Gold
Word Q + Speak Q
Inspiration
Solo
Ginger
Case Study…Computer Access
38 year old female veteran
Army 8 years
University of South Carolina as Administrative Assistant
Divorced with 2 children
2006 Brainstem meningioma s/p surgical resection and
radiation therapy with post radiation necrosis
Shunt in 2006
Right Hemiplegia
Mild Visual Impairment
Severe to Profound Dysarthria
Case Study-Computer Access
Comprehension intact
Memory intact
Attention span good
Current AT Equipment
◦ Invacare 5000
◦ Dynawrite
Goals:
◦ “Email, shopping”
◦ “Get my masters”
Environment
◦ Parents Home
◦ Computer Locations
Bedroom
Living Room
Case Study-Computer Access
Mouse
◦ Trackball
◦ Sticky keys
◦ Joystick mouse
◦ Enlarge Cursor and Pointer
Text
◦ Mini keyboard
◦ BIG KEYS Yellow keyboard
◦ Word Q
◦ ZoomText
Mouse
◦ Joystick mouse with sticky keys
◦ Enlarge Cursor and Pointer
Text
◦ BIG Keys Yellow keyboard
◦ Word Q
◦ ZoomText
Trailed Results
Research
Information about tools for computer
access
Pediatric and Stroke literature
Spinal Cord and Vision literature
Overview of EADLs (ECUs)
A.K.A. – Environmental Control Unit (ECU)
EADLs provide a means for someone with limited functional mobility or dexterity to interact with their environment
Most any device can be controlled◦ A Light or fan
◦ Television, radio, and cable box
◦ Air conditioner thermostat
◦ Telephone
◦ Hospital bed
◦ Window blinds or drapes,
◦ Door and camera
Overview of EADLs, cont.
Control Unit
LightFan
Door opener
Television
Cable boxTelephone
Bed controller
User
The Patient – Most Important
Who Qualifies?
◦ Anyone who is unable to access items used in daily life
Television, cable box
Hospital bed, nurse call
Door, light switches
◦ Quality life and independence are important factors
◦ Example diagnoses: ALS, SCI, TBI, Locked in Syndrome
User
The Patient – Considerations
Physical ability?
◦ Determines access method
◦ Evaluate with low technology
◦ Consider progression
Cognitive ability?
◦ Determines ECU complexity
◦ Static or dynamic
Mental Status
◦ Level of tolerance, patience, and/or PTSD
◦ Help to determine device applicability
Home environment?
◦ Determines ECU type and applicability
◦ House, apartment, or long term care facility
◦ Single or multi-room
User
User Environment
Control area◦ Single room Typically the bedroom
Mounted to bed frame
Generally simpler installation
◦ Multi-room Mobile - control multiple rooms
Wireless base station or self contained
Typically wheelchair based
Mobile unit is battery powered – possibly by wheelchair
Mounting ◦ ECU, switch, and/or microphone
◦ Wheelchair, bed, and/or floor stand
User Interfaces - Direct Standard / adapted control
◦ Most efficient access method
◦ Keyboard, mouse, touch screen, mouth stick, joystick, chin joystick, etc.
Voice control◦ Totally hands free – typically more sensitive
◦ Switch initiated – more forgiving
◦ Various menu structures and complexities
◦ Consider user vocal amplitude and phonation capability
◦ Disposition is important (Back ground noise)
◦ Backup indirect switch access is a good idea
User Interfaces - Indirect
Scanning
◦ Options are incremented through and selected when highlighted
◦ Inefficient access method
◦ Requires consistent and accurate switch activation
◦ Single switch - selects and auto scanning
◦ Double switch - one scans and one selects
Directed scanning
◦ More efficient, but more complex than normal scanning
◦ Directional scanning control
◦ Available option for some alternate communication devices
Coded access
◦ Very efficient, but not used often
◦ Morse code
Transmission Methods -
Remotes
Infra-red (IR)
• Television remote
• Line of sight communication - bad
• Portable
• Learning remotes
Radio Frequency
• Simple remotes
• Garage door openers
• Not line of sight communication – good
Transmission Methods -
Automation Home Automation Systems
• Used to control lights, doors, thermostats, etc.
• Power-line Uses existing AC house wiring
Inexpensive
Sensitive to power-line noise
House wiring affects operation
X10, Insteon
• Home networks Wired local area network
(LAN)
Wireless RF networks• Z-wave, Wifi, Bluetooth
Wi-Fi becoming more viable
ECU Devices
Direct input only• X10 PalmPad RF control of 16 devices
Only 8 channels at one time
• X10 SlimFire remote Radio Frequency (RF) control of 2 channels
Small keychain size
Dimmer control
• X10 Mini timer 8 channel on/off timer
• Insteon RemoteLinc 6 on / off buttons
Control 6 scenes (multiple devices per button)
$22SmartHome
$22SmartHome
$39.99SmartHome
$59.99SmartHome
ECU Devices, cont.
Direct / indirect input• Relax II Switch Input (1-2)
IR learning (4 devices, 10 commands each)
Preprogrammed RF X10 (10 devices)
Battery powered
Requires X-10 RF transceiver
• Primo! Touch screen and switch input (1-2)
Auditory and visual feedback
IR learning (many devices)
Preprogrammed IR X10 (8 devices)
Ready for Sero! phone control
Battery and AC powered
Requires X-10 IR commander
$729Ablenet
$2,700Ablenet
ECU Devices, cont.
Voice activated
• Pilot one Ablenet, $2,100
Voice or switch input (1-2) with auditory and visual feedback
Must train to user voice and commands
IR learning (10 devices, many commands each)
Preprogrammed IR X10 (4 devices)
Ready for Sero! phone control
Battery and AC powered
Requires X-10 IR commander
• Quartet Simplicity AIO Quartet, $14,000
Voice or switch input (1-2) with auditory feedback
Must train to user voice and commands
IR learning (6 devices)
Preprogrammed X10 (64 devices)
Built in telephone
Battery and AC powered
$2,100Ablenet
$14,000
Quartet
ECU Devices, cont.
Telephone access Ablephone 6000 (Vocally Infinity)
• AblePhone or EnableMart, $219
• Voice controlled telephone dialer
• Combine with the Ameriphone RC200 for switch based or hands-free operation
• Must train to user voice
Ablephone 7000VC• AblePhone, $579
• Total voice control solution
• Auditory feedback
• Must train to user voice
Sero!• Ablenet, $1,195
• IR controlled phone
• Needs Primo!, Pilot, or other ECU for hands-free operation
• Auditory and visual feedback
$219Ablenet
$579Ablephone
$1,195Ablenet
ECU Devices – Other Options
Wheel chair interface
• Quantum
Q-Logic enhanced display
Add on display for wheel chair controls
IR control (learning)
Bluetooth mouse
• Permobil
R-Net Omni
IR learning
• Invacare
Mouse emulator
No IR control
ECU Devices – Other Options,
cont. Augmentative and Alternative
Communication (AAC) Devices with IR
control ability
TobiiC12
DynavoxMaestro
PRCECO2
ECU Devices - New Options
Usage of mobile devices and computers to interface to home automation systems
Insteon Home Linc
X10 Activehome Pro
Pros
• Consumer products (cost efficient and appealing)
• Can use conductive mouth stick for touch screen access on mobile devices
• Computer – many adapted access methods
Cons
• Scanning input is not mature (yet) iOS 6 Voiceover and Tecla Shield for scanning
Android 4.0 has Bluetooth mouse control
• Voice activation not integrated into home automation apps / software (yet)
ECU Devices - New Options
IR remote control adapters for computer and mobile devices• Computer – Wifi or USB
connection
• iOS and Android devices –Wifi, headphone, or dock connection
• Requires software or App
• Use for basic television control or home automation access
Smart Environments
ECU Devices - New Options
Home automation interfaces
• Software or web interface
• Requires Wifi / ethernet connection, or USB
adapter
• Mobile devices
iOS and Android based apps available
iPhone / iPod touch / Android OS cell phones
iPad / Android tablets – good for low vision
Case Study-EADLS - RUSS
History
◦ 37 year old male veteran
◦ C4 AISA C
◦ Dysarthria, decreased inspiratoryand expiratory strength/volume
◦ Uses chin control on PermobilC500 wheelchair
Consult
◦ Independent computer access
◦ ECU
◦ AAC
Desire for access to lights, television, and front door.
No desire to use ECU in bed
Case Study-EADLS, cont.
◦ Computer access
Headmouse, QuadJoy, and Quadmouse
Bluetooth module on Permobil wheelchair and chin joystick
Dwell click, headrest mounted switch
◦ AAC
AT consulted for access method (similar to computer access
Dynavox Maestro and Tobii devices
◦ ECU
Goals of patient determined
Demonstration scanning access with Relax 2 and Primo!
AAC ECU functionality explained
Evaluation Collaboration: OT,
SLP, RE
Case Study-EADLS, cont.
Initial Results
◦ AAC, wheelchair, and ECU integration through
Bluetooth mouse module and chin joystick
◦ AAC / computer access
Dwell mouse click for computer (AAC) access
Independent AAC on/off control using IO module
AAC power supply adapter for wheelchair
◦ ECU
Television control through AAC and wheelchair
X-10 light control using IR commander (line of sight)
X-10 operated door opener for front door
Sero! IR telephone for emergency calls
Case Study-EADLS, cont.
Follow-up Results:
◦ Post installation
Access to AAC and ECU while in bed
Door opener only works from inside the house
Sero! telephone incompatible with DSL land-line
◦ Second Prosthetics Service consult
Swap telephone with Broadened Horizons model
Add door opener control to IO module on wheelchair
◦ Re-trial Quadmouse, QuadJoy with floor stand
AAC mounts
Research
Minimal research in this area of EDALS
specifically
◦ outcome data is needed to support the use
of ECU
◦ Education to 3rd party payers
◦ Training of rehabilitation therapists is
critical
Need for research in the use of these
devices in the workplace
Veterans’ story
FUTURE OF ASSISTIVE TECHNOLOGY IN THE REHAB WORLD
TELEHEALTH, AT & PM&R
OPPORTUNITY
KNOCKING
TeleHealth
What is TeleHealth Major Benefits
• Providing health care
services through the use of
technology (i.e. video
conferencing equipment)
• allows patients to have improved access to healthcare services;
• is more convenient for patients and caregivers; and
• enables and improves primary and specialty care provider collaboration to optimize patient care outcomes.
TeleHealth, AT & Rehabilitation
Provide 1:1 consultation for any areas of AT
Provide AT Evaluations
Provide patient group education for any of the areas of AT
Use of Technology for remote sites and home based primary care
AT & TeleHealth…Opportunity
Knocking Follow up to the usage of
AT after discharge
Remote support on the Job Site, School, Community and/or Home
Consultation with AT Rehab Engineering Team
Provide staff in-services on any of areas of AT and/or specific device training
Brain Interface Brain Control Devices (BCD‟s)
Quantum to Nanocomputing
Nanocomputers ?
“We have already succeeded in creating a biological automation made of DNA and proteins able to diagnose in a test tube the molecular symptoms of certain cancers and „treat‟ the disease by releasing a therapeutic molecule”. http://www.shandyking.com/2006/05/05/new-nano-computer-species/
They plan to spray the nanocomputers on to the chests of coronary patients, where the tiny cells would record a patient‟s health and transmit information back to a hospital computer.
http://radio.weblogs.com/0105910/2003/08/19.html
Robotics and Androids Personal Robotic
Service Robotic ◦ Healthcare
◦ Canine service dog robotics for the blind
Security & Defense
Industrial Robotics
Academic & Research
Therapeutic Robots VGo
Final Points…
Communication
Collaboration
Education
Team Building
Share your expertise
Provide support
Education on types
of AT devices
Education on the
usage of those
devices
AT Resources
AbleData◦ http://abledata.com/
Alliance for Technology Access◦ http://ataccess.org/
Assistive Technology Industry Association (ATIA)◦ http://atia.org/
Closing the Gap◦ http://closingthegap.com/
CSUN Technology and Persons with Disabilities Conference◦ http://csun.edu/cod/conf/
DO-IT Technology and Universal Design◦ http://uw.edu/doit/resources/
tehcnology.html
EmpTech◦ http://emptech.info/
RESNA◦ http://resna.org/
TraceCenter◦ http://trace.wisc.edu
Association of AT Act Programs◦ http://ataporg.org
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